Summary: Ms W complains about the care her father received at Haresbrook Park Care Home in the period before his death. We find the Council at fault for some parts of the care it commissioned. In addition to the service improvements already made, the Council has agreed to apologise and make a symbolic payment in recognition of the avoidable distress caused to Ms W.

The complaint

1. Ms W complains about the care Mr Y received whilst resident in Haresbrook Park care home. Her concerns include:
1. inappropriate handling of Mr Y by a care worker.
2. lack of staff monitoring and oversight, especially during weekends.
3. failure to provide Mr Y with adequate hydration.
4. failure to identify and seek prompt treatment for a suspected infection.

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The Ombudsman’s role and powers

2. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions. Part 3A is for complaints about care bought directly from a care provider by the person who needs it or their representative, and includes care funded privately or with direct payments using a personal budget. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(1), as amended)

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What I have and have not investigated

5. I have investigated the actions of the care provider, Haresbrook Park, as a provider commissioned by the Council. I have not investigated the actions of any medical professionals. Complaints about any clinical decisions made by those individuals would be a matter for the relevant NHS bodies and Parliamentary Health Service Ombudsman (PHSO).

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How I considered this complaint

6. I considered evidence provided by Ms W, the Council and the care provider as well as relevant law, policy and guidance.
7. Ms W and the Council had an opportunity to comment on my draft decision. I considered any comments before making a final decision.
8. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

9. Mr Y became a resident at Haresbrook Park (‘the home’) in March 2025. Previously, Mr Y had lived with family members and received domiciliary care however Mr Y’s family felt his needs had increased and he needed 24-hour support.
10. In July 2025, Ms W approached the home to discuss the possibility of installing a camera in Mr Y’s room to monitor his movements at nighttime. The home says that, before this, Ms W had been happy with the care provided to Mr Y and had raised no concerns. The home said it would consider serving notice to end Mr Y’s placement if the family continued to ask for a camera in Mr Y’s room.
11. Around this time, Ms W reports an influx of wasps in the home. Records show the home arranged for pest control to treat a wasp nest. Ms W suspects that Mr Y may have sustained a wasp sting or an insect bite in early July.
12. Mr Y suffered a fall in mid-July. The home recorded its observations, notified Mr Y’s family and monitored him. The home noted that Mr Y’s appetite decreased but that it was a hot day which in turn affected the appetite of many of the residents.
13. The following day a care worker noted that Mr Y was sleepy with no appetite. Mr Y’s observations were normal, but staff noted he did not seem his usual self. The care worker called the NHS non-emergency number 111 for advice.
• At around 6pm a GP attended the home to review Mr Y. In conjunction with the family, the GP decided not to send Mr Y to hospital for treatment. The home agreed to make Mr Y comfortable.
• Some hours later Ms W raised concerns about swelling to Mr Y’s arm and asked the home to call 999.
• At around 9pm the home had a telephone consultation with a GP who advised care staff to take Mr Y’s observations hourly and to apply a cold patch to the swollen area of his arm.
• At 2am the GP reviewed Mr Y again and prescribed antibiotics and requested a blood test to check for signs of possible infection.
14. The following morning the home called a nurse to arrange a blood test for Mr Y. The nurse agreed to attend in the afternoon.
15. Mr Y passed away later that day.
16. Following the death of Mr Y, his family raised concerns with the home about the events leading to Mr Y’s deterioration. In particular, they said the home had not documented nor sought appropriate treatment for the swelling on Mr Y’s arm.
17. In August 2025 the care home raised a safeguarding concern about the actions of a care worker who was no longer working at the home. The home explained how it had reviewed CCTV footage in response to Ms W’s complaint and found evidence that the care worker used incorrect moving and handling techniques with Mr Y in the week before his death. The footage showed the care worker had pulled Mr Y up from his chair by his hands which could cause bruising.
18. An officer from the Council’s ‘Quality Assurance’ (QA) team visited the home in September 2025 and found that care workers completed and reviewed body maps for residents with wounds but did not include skin checks in planned care. The Council also looked at staffing levels but noted no concerns.
19. The Council identified some areas where the home needed to improve but found no immediate risks to residents. The Council ended its QA monitoring in November 2025.

Was there fault in the actions of the Council causing injustice?

Complaint a)

20. Before his death, Ms W says Mr Y told her that one care worker was ‘rough’ with him. She says the home did not properly investigate this concern.
21. In response, the home reviewed CCTV footage covering a 13‑day period in July 2025. As Mr Y said the incident occurred in the evenings, the home focused on footage from 6pm onwards.
22. This review identified one occasion where a care worker did not follow the correct moving and handling procedure. The home considered this could account for bruising to Mr Y’s right hand, which had been incorrectly recorded as a wrist injury. This was fault, which caused injustice.
23. The footage also showed a separate incident where another resident held Mr Y’s arms, which may also have contributed to bruising.
24. The home accepted there was fault in its record keeping, including not completing incident reports properly and inconsistencies in body maps. It has since taken action to address this through management supervision and additional staff training.
25. I recognise Ms W’s view that further concerns were raised but not recorded. However, in the absence of contemporaneous records or independent evidence, I cannot make further findings on this point. In the circumstances, and based on the available evidence, I consider the home took reasonable steps to investigate the concern. With that said, the fault identified caused injustice to Ms W in the form of distress which the Council will provide a remedy for.

Complaint b)

26. Ms W said the lounge area was poorly monitored by the home, especially at weekends. As a result, she says Mr Y could not call for help when he needed assistance. This meant he sometimes mobilised without help and fell over.
27. During Mr Y’s time at the home, staff recorded that he fell on eight occasions, three of which happened in the lounge area. Two of those falls were recorded as unwitnessed and the third recorded as a controlled fall.
28. Upon review of the CCTV footage, the home decided that staff had incorrectly documented one of the two unwitnessed falls as the footage showed a member of staff attempting to support Mr Y when he stood from his chair. Mr Y lost his balance, fell backwards and hit his head and left shoulder against the wall before falling onto his right shoulder.
29. The home said the nature of the fall was consistent with the bruising recorded to both shoulders as well as the head injury, which the home contacted NHS 111 to seek advice for.
30. Despite having measures in place to reduce the risk of falls, including sensor mats and regular observations, the home said Mr Y sometimes unplugged the sensor mat. In light of this, the home now accepts it should have increased the frequency of observations to hourly. The shortfall in observations was fault causing injustice to Ms W in the form of avoidable uncertainty, as she cannot now know whether more frequent observations would have reduced the risk to Mr Y.

Complaint c)

31. Mr Y’s care plan noted the need to “monitor my food and fluid intake”. Up until late June, Mr Y is reported to eat and drink well. By 12 July, this had changed and the home recorded Mr Y as being off his food and drinks. By 14 July, Mr Y was struggling to drink and needed staff to offer small sips and encourage him or keep his mouth moist if he could not manage a drink.
32. The care notes show that staff offered drinks regularly and intake was recorded throughout July 2025, with generally good intake in the earlier part of the month. Mr Y’s intake declined in the days before 13 July and reduced significantly from 13 July with several recorded refusals and minimal fluid intake. This is consistent with Mr Y’s deteriorating condition at the end of his life.
33. While Ms W reports CCTV footage suggested drinks were sometimes placed out of Mr Y’s reach, I have not seen that footage. In the absence of evidence to contradict the care records, I have placed weight on the contemporaneous documentation, which shows regular offering of fluids and I find no fault.

Complaint d)

34. The records show the home sought medical input when Mr Y’s condition deteriorated in mid‑July. Staff contacted NHS 111 when he appeared unusually sleepy and had no appetite. A GP attended later that day and, in discussion with the family, decided Mr Y should remain at the home for his comfort.
35. When Ms W raised concerns about swelling to Mr Y’s arm, staff contacted emergency services at the family’s request. Mr Y was subsequently reviewed by a GP once that evening and again overnight, with advice given to monitor his observations hourly, apply a cold compress to the affected area, and commence antibiotics. Arrangements were also made for blood tests the following day.
36. We are not investigating the actions of NHS clinicians as part of this case. I have therefore focused on the complaint that the home failed to identify or seek appropriate treatment for Mr Y’s symptoms.
37. I understand the blood test did not proceed. This was the day during which Mr Y declined rapidly and later died. I acknowledge Ms W’s view that earlier identification or treatment could have altered the outcome. However, determining whether different medical intervention would have changed the outcome is a matter of clinical judgement. Decisions about diagnosis and the necessity for investigations or treatment were made by NHS professionals and are not matters I can investigate.
38. On the evidence available, the home escalated concerns promptly and followed the clinical advice given. I find no fault.

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Action

39. Where someone has died, we will not normally seek a remedy for injustice caused to that person in the same way as we might for someone who is still living. We would not expect a public or private body to make a payment to someone’s estate. Therefore, if the impact of a fault was on someone who has died, we will not recommend an organisation make a payment in recognition of, for example, the impact of poor care that person might have received while they were alive.
40. This is because the person who received the poor care cannot benefit from such a payment. However, if we consider the person who has complained to us has been adversely affected by seeing the impact of that poor care on their relative, we may recommend a symbolic payment to them as a remedy for their own distress.
41. The provider has already offered a general apology and set out service improvements. However, this apology did not specifically recognise the faults identified in this investigation or the impact on Ms W.
42. The faults I have identified, particularly the failure to properly record and follow up concerns about care, and the failure to increase observations despite known risks, caused Ms W avoidable distress and uncertainty about whether Mr Y’s care needs were properly recognised and addressed in the period before his death.
43. In light of this, the Council has agreed to:
• apologise to Ms W for the fault identified in this statement. This is in addition to the general apology already provided. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Council will consider this guidance in making the apology I have recommended in my findings.
• make a symbolic payment of £250 in recognition of the distress caused by the fault identified in this statement.
44. I have decided not to recommend service improvements because the care provider has already taken steps to improve the service following the complaint, such as:
• regular staff learning through a weekly “Topic of the Week” focusing on key areas such as recognising deterioration, falls management, hygiene and safe care practices.
• increased overall staff training compliance and provided additional training, including tissue viability. These actions are intended to improve staff knowledge, strengthen day‑to‑day care, and support earlier identification and escalation of changes in residents’ condition.
45. The Council will provide us with evidence it has complied with the above actions.

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Decision

46. I find fault causing injustice. The Council will complete the above actions to remedy injustice caused by fault.

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Investigator's decision on behalf of the Ombudsman